Early pregnancy Flashcards

Question

Management of suspected molar pregnancy

Answer 1

Suction evacuation / curettage - Preferred initial management - May use US guidance to minimise chance of perforation - Medical methods a/w higher rates of chemotherapy - Preparation of the cervix immediately prior to evac is safe - Oxytocin infusion can be used after if brisk bleeding occurs - Senior / experienced surgeon present - Anti D if Rh negative Hysterectomy not recommend for treatment of molar pregnancy alone

Answer 2

Partial - Weekly until 3 consecutive normal levels, then stop Complete - weekly until 3 consecutive normal levels, then monthly for 6 months Review at 8-10 weeks (provided HCG falling appropriately) to check that menstruation has returned and that adequate contraception is being followed If tHCG still positive at this point, d/w gynae oncologist Risk of GTN after end of appropriate follow-up: - 0% for partial moles - 0.3% for complete moles

Answer 3

1. Plateau of hCG lasts for 4 measurements over a period of 3 weeks or longer 2. Rise of HCG on 3 consecutive measurements, over a period of 2 weeks or longer 3. Histologic diagnosis of choriocarcinoma

Answer 4

Strongly advised to avoid pregnancy during follow-up as it may mask tumour persistence / recurrence Oral contraceptives can be taken IUCDs should be avoided - Until menstrual pattern and tHCG are normal to reduce perforation risk Barrier methods preferred during chemotherapy Don't conceive until follow up is complete In all subsequent pregnancies should have an early and mid trimester scan looking for molar tissue After all future pregnancies (including TOP, miscarriage), should have tHCG at 6-8 weeks - RCOG - no longer have to do, risk of GTD in subsequent pregnancy is very low (1:4011) in women who have not received chemotherapy for a prior molar pregnancy Chances of conception does not different from general population Risk of further molar pregnancy in future pregnancies is 1:70 LBR in subsequent pregnancies ~70%

Answer 5

Bloods - Baseline tHCG - FBC, U&E, TFTs, coags - HBsAg - LFTs - to assess for metastases - Consider cross-match if heavy bleeding Radiology: - CXR - Pelvic USS (TVS preferred) If pulmonary metastases or abnormal exam: - CT abdo and pelvis - MRI brain

Answer 6

FIGO 2000 criteria Low risk <6 - Cure rate almost 100% - IM methotrexate, 2 weekly OP regimen - Continue until normal HCG + further 3 cycles - 1 in 4 become resistant to Rx --> EMA-CO or Actinomycin - consider second erpoc in low risk patients, (FIGO risk score 0-4) - 40% may avoid chemo High risk >7 - Cure rate is 94% - MDM guided Rx, likely multi-agent Consider hysterectomy for GTN in women who have completed their family and GTN confined to the uterus, to reduce the need for chemotherapy

Answer 7

Re-check sites of original disease (imaging) tHCG follow up - Low risk --> monthly for 12 months - High risk --> month for 2 years If abnormal, exclude pregnancy, then urgent referral to Med Onc Contraception advised for >1y after last dose of chemotherapy - Prevent pregnancy obscuring relapse - Reduce the incidence of abnormal pregnancies Risk of relapse - 3.5% - Median time to relapse is 4/12

Answer 8

Fertility unlikely to be affected - Further pregnancies in ~80% Wait >1y after last chemotherapy dose 1 in 70 chance of conceiving further molar pregnancy If conceive within 12 months of chemotherapy: - No indication for recommendation of TOP - Increased risks - spontaneous abortion, stillbirth, repeat mole - RANZCOG - if receive multi-agent chemotherapy may be at increased risk of early pregnancy complications if conception occurs within 12 months of completion of Rx

Answer 9

~1 in 50,000 pregnancies Most commonly follows a complete molar pregnancy (25-50%) - Within 12 months of a non-molar abortion (25%) - After a term pregnancy (25-50%) Difficult pathological Dx as frequent haemorrhage and necrosis This is a tumour that crosses the placenta, therefore newborn born to a mother newly diagnosed with choriocarcinoma needs to be investigated to exclude disease (urinary HCG)

Answer 10

0.2% of all GTD Produce less HCG Confined to the uterus for longer More chemoresistant than other forms of GTN Most important prognostic factor: interval to presentation from last known and presumed causative pregnancy Primary treatment: hysterectomy

Answer 11

Double in 48h | Lower limit of normal 66%

Answer 12

Occurs in ~20% of pregnancies - ~30% post-implantation and biochemical pregnancy loss rates <5% of miscarriages occur after identification of fetal heart activity

Answer 13

Maternal age - 40-44 = 50% Paternal age Number of previous miscarriages - After 3 consecutive pregnancy losses, risk of further miscarriage is ~40% Any severe infection that leads to bacteraemia or viraemia can cause sporadic miscarriage Factors associated with reduced risk of miscarriage: - Previous live birth - Nausea - Vitamin supplementation - Feeling well enough to fly or have sex - Eating fresh fruits and vegetables daily Factors with no evidence of association with miscarriage: - Caffeine consumption - Smoking - Moderate or occasional alcohol consumption - Education level - SES - Working during pregnancy

Answer 14

7-14 days If resolution of bleeding and pain indicate successful expectant management, take urine HCG 3 weeks later Infection rate is low at ~3% From available RCTs, no increased risk of infection or pain Fewer GI side effects Patient satisfaction no different Chances of unplanned intervention, need for blood transfusion, and prolonged bleeding are higher in the expectant group compared to active intervention group Overall success rates after 14 days - 70-80%

Answer 15

Efficacy ranges from 80 to >90% - Varies with gestational age (higher if <9/40), presence of pv bleeding (onset prior to Rx), duration of f/u - Mife + miso vs. miso alone - 88% vs. 71% ``` RPOC requiring surgical evacuation (8-9%) Blood transfusion (2%) Pelvic infection (<1%) ``` If IUCD in situ, should be removed before administration of mifepristone

Answer 16

``` Efficacy highest (up to 100%) No substantiated evidence in the literature of any impact on future fertility ``` ``` Uterine perforation (up to 5 in 1000) Intra-abdominal trauma (0.1%) Blood transfusion (1-2 in 1000) Need for repeat surgical evacuation (up to 5%) Localised pelvic infection (3%) ```

Answer 17

Of cervical prep for 1st trimester ERPOC - Decreases length of procedure - No good evidence reduces cervical trauma or perforation - as these are rare events For 2nd trimester use osmotic dilators rather than miso Prophylactic antibiotics reduce upper genital tract infection - No consensus on best regime

Answer 18

loss of three or more consecutive pregnancies Affects 1% of couples Can be primary or secondary

Answer 19

AMA (13% in those >40) Antiphospholipid syndrome - Antibodies present in up to 20% of women with recurrent miscarriage (c.f. 2%) Chromosomal abnormalities of the embryo - ~50% of miscarriages Parents who are carriers of a balanced translocation - most commonly Robertsonian translocation - Found in 3-5% of recurrent miscarriage couples Anatomical factors - uterine malformation, cervical weakness Overt hypothyroidism Diabetes PCOS Male factors - Comparing sperm from couples with RPL to those without - lower percentage of normal sperm morphology, concentration and progressive motility Inhibited thrombophilias

Answer 20

Pelvic USS Antiphospholipid antibodies Booking bloods Thyroid and diabetes screen Consider thrombophilia screen Cytogenic analysis should be performed on POC of the third and subsequent consecutive miscarriages Parental peripheral blood karyotyping of both partners should be performed if POC testing reports an unbalanced structural chromosomal abnormality 83% chance of successful pregnancy if balanced karyotype

Answer 21

Increasing evidence that patients with RPL may be a high-risk population for adverse obstetric outcomes - Retrospective cohort found increased PET, PTB, SGA, abruption and stillbirth <37/40 Women who suffer recurrent miscarriages are an increased risk of future CVD - Independent of BMI, HTN, WCC

Answer 22

Excellent prognosis for pregnancy outcome (~75%) without pharmacological intervention if offered supportive care alone in the setting of a dedicated early pregnancy assessment unit - No evidence for aspirin +/- heparin in these women Smoking could have a negative impact on chances of LBR, therefore cessation is recommended Recommend aiming for normal / healthy BMI Excessive alcohol is a possible risk factor, therefore advise to limit consumption General advice to consider prophylactic vitamin D supplementation - Based on significant prevalence of vit D deficiency in women with RPL and possibly a/w complications Evidence for effectiveness is absent, but considered safe No evidence for IVF or HCG supplementation

Answer 23

Cochrane 2021 - Progestogens probably make little or no difference to live birth rate for women with threatened or recurrent miscarriage - However, vaginal micronized progesterone may increase the live birth rate for women with a history of one or more previous miscarriages and early pregnancy bleeding, with likely no difference in adverse events RANZCOG - general pop - no change to miscarriage - threatened misc - may reduce rate, therefore consider - RPL - doesn't improve outcomes - give following IVF - theoretical possibility of cleft lip

Answer 24

low-dose aspirin starting before conception and prophylactic dose LMWH starting at date of positive pregnancy test Reduces miscarriage rate by 54% compared to aspirin alone Neither steroids or IVIG improve LBR LBR only 10% without intervention

Answer 25

``` Finding of abnormal parental karyotype --> prompt referral to clinical geneticist, offers the couple a prognosis for the risk of future pregnancies with an unbalanced chromosome complement and the opportunity for familial chromosome studies Higher chance (50-70%) of healthy live birth in future untreated pregnancies following natural conception than is currently achieved after pre-implantation genetic diagnosis / IVF (~30%) ```

Answer 26

Heparin therapy may improve the LBR of women with second trimester miscarriage a/w inherited thrombophilias Cochrane - prophylactic clexane a/w no clear difference

Answer 27

Insufficient evidence to assess the effect of uterine septum resection in women with recurrent miscarriage and uterine septum to prevent further miscarriage Retrospective evidence - improved LBR / reduced miscarriage

Answer 28

1 in 4 pregnancies will end in abortion 1 in 4 women will have an abortion In Australia, 4% of abortions performed 14-20/40, only 1% >20/40

Answer 29

Early medical abortion <9/40 Minor surgical procedure under LA - 9-15/40 Surgical abortion under GA - 5-20/40 Early IOL >14/40 IOL >20/40

Answer 30

Abortion has been blamed for psychological damage, but there is little evidence for this Factors that may predict negative psychological outcomes: - Certain personality traits including impulsivity, attachment, low self esteem and dependency - Late gestation abortion - Prior psychiatric illness - Conflict with religious or cultural beliefs PTB due to cervical damage with recurrent abortions (mixed findings)

Answer 31

Access should be on the basis of health care need and should not be limited by age, SE disadvantage or geographic isolation - Non-availability of abortion services has been shown to increase maternal morbidity and mortality Women should have access to professional counselling Health practitioners should be aware of the legislation regarding abortion where they practice Prevention of unintended pregnancy should be a priority

Answer 32

All women should be given accurate info and counselling should be available Clinical assessment including medical Hx and exam Exclude contraindications Accurate gestational assessment USS to confirm gestation and exclude ectopic Consider screening for STI and/or antibiotic prophylaxis Blood group and Rh(d) status +/- anti-D POC treated in accordance with local and legislative protocols Plan for future contraception Written consent should be obtained prior to the commencement of treatment

Answer 33

``` Surgical evacuation Most common risks - Bleeding requiring transfusion <1% - Low grade fever 1-2% Serious risks - Uterine perforation <1% - Injury to bowel or large vessels <1% - Uterine rupture with use of misoprostol <1% ``` ``` IOL Common risks - Retained placenta requiring OT 10% - Low grade fever 30% - Prolonged procedure 6-20% Rare - Bleeding requiring transfusion 1% - Uterine rupture with use of misoprostol <1% ```

Answer 34

``` Allergy to the drugs involved IUD in situ after failure to remove it Chronic adrenal failure - Mife may have general anti-glucocorticoid actions Severe asthma Chronic renal disease Porphyrias Addison's disease ```

Answer 35

``` Hospital admission is mandatory Mifepristone - 200mg 24-36h prior to admission - Reduces inpatient time to delivery by up to 50% - 1% chance of outpatient delivery ``` Misoprostol 400-800mcg PV then 400mcg q3h until delivery Complications - Retained placenta in 10% needing OT - Transfusion in 1-2% - Fetus live at birth in 1.5% - Ruptured uterus - 1% with previous CS

Answer 36

After 14/40, osmotic dilators superior to medical methods, but misoprostol is acceptable up to 18/40 2 stage procedure Evacuate fetus with forceps under USS guidance Empty uterus with suction / curette Cervical priming mandatory Failure rates not reported - extremely rare Major complications 6-15/1000 depending of gestation

Answer 37

Ultrasound guided intracardiac injection KCl + lidnocaine TOP >22/40 Feticide in multiples - 7-10% miscarriage risk DCDA twins - Intracardiac KCl for discordance in fetal anomalies MC twins - Complicated due to fetal vascular connections - Requires cord interruption

Answer 38

Prostaglandin analogue Has a direct effect on the uterus and cervix, causing uterine contractions and cervical dilatation, resulting in bleeding Onset of action = 30 mins Sublingual - most rapid effect

Answer 39

Synthetic anti-progesterone Blocks the effects of progesterone Sensitises the myometrium to prostaglandin induced contractions --> decidual breakdown and cervical ripening

Early pregnancy Flashcards

(63 cards)